Original Article Revision surgery for femoral shaft aseptic nonunion associated with broken distal locked screws q Chia-Wei Yu * , Chi-Chuan Wu Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kweishan, Taoyuan, Taiwan Keywords: femoral shaft nonunion locked screw breakage cancellous bone graft abstract Purpose: This retrospective study was to report the experience in treating femoral shaft aseptic nonunions associated with breakage of distal locked screws. Materials and Methods: Thirty-two femoral shaft aseptic nonunions associated with breakage of both distal locked screws in 30 consecutive adult patients with 32 nonunions were treated. Eleven nonunions were concomitantly associated with at least 1.5 cm (1.5e3.5) shortening. These 11 nonunions were treated by one-stage nail exchange and femoral lengthening, static locked nailing stabilization, and corticocancellous bone graft supplementation, whereas other 21 nonunions were treated with less than 1.5 cm shortening, simple exchange nailing only. Results: Twenty-eight nonunions were followed-up for a median of 3.8 (1.1e6.2) years and 26 fractures healed at a median of 4 (3e9) months. Either group had one persistent nonunion (p ¼ 0.48) and was successfully treated with repeated exchange nailing or open cancellous bone grafting. Conclusions: Using exchange locked nailing or one-stage femoral lengthening to treat femoral shaft aseptic nonunion associated with broken distal locked screws can achieve a high success rate. The key of the technique to remove broken screws is withdrawing the nail a little bit to release the incarcerated broken screw end. Then, the screw end is pushed out with a used Knowles’ pin or a smaller size screwdriver under the image intensifier guidance. Copyright Ó 2011, Taiwan Orthopaedic Association. Published byElsevier Taiwan LLC. All rights reserved. 1. Introduction Despite that unlocked or locked reamed intramedullary nails have been the treatment of choice for most of femoral shaft frac- tures, a nonunion rate may still be as high as 10%. 1,2 A femoral shaft nonunion following locked nail stabilization may be sometimes associated with implant failurednail or distal locked screw breakage, which consequently worsen the fracture stability. Articles reporting treatment of a femoral shaft nonunion asso- ciated with breakage of a locked nail are not few. 3 On the other hand, to the best of the authors’ knowledge, articles reporting treatment of a femoral shaft nonunion associated with breakage of distal locked screws are rare. Although an incidence of 0%e8% has been reported as an aside in the literature, all cases are imputed to using a small caliber of locked screws for a small diameter of locked nails. 4,5 Methods used to treat such a disorder may be multiple. Theo- retically, revision with a new intramedullary nail should be rela- tively better. However, articles reporting techniques of revision with a new intramedullary nail are few. Moreover, sample sizes of these articles are so small that the outcome of treatment is still uncertain. 5,6 Whether is revision with a new intramedullary nail a better choice? The aim of this retrospective study was to review the technique of revision with a new intramedullary nail with or without simultaneous correction of shortening. The feasibility of this technique was thoroughly investigated. 2. Materials and methods From October 2000 to November 2006, 32 femoral shaft aseptic nonunions associated with breakage of both distal locked screws in 30 consecutive adult patients (>15 years) were treated at the authors’ institution. Patients aged a median of 29 (19e56) years with a male to female ratio of four to one. Twenty-eight nonunions were unilateral and two nonunions were bilateral. All nonunions were caused by failed fracture treatment before, and all fractures were initially caused by vehicle crashes. Twenty-five fractures had been treated initially at other hospitals. The previous q No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. * Corresponding author. Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Kweishan, Taoyuan, Taiwan. Tel.: þ886 3 328 1200x3612; fax: þ886 3 327 8113. E-mail address: doctor.vincent@gmail.com (C.-W. Yu). Contents lists available at ScienceDirect Formosan Journal of Musculoskeletal Disorders journal homepage: www.e-fjmd.com 2210-7940/$ e see front matter Copyright Ó 2011, Taiwan Orthopaedic Association. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.fjmd.2010.12.008 Formosan Journal of Musculoskeletal Disorders 2 (2011) 2e6